K:\ABPH\Application for ABPH 2007.doc Page 3 of 4
AMERICAN BOARD OF PSYCHOLOGICAL HYPNOSIS
Elgan Baker, Ph.D., ABPH, President
Application for Diplomate Examination in:
_____Clinical Hypnosis _____Experimental Hypnosis
Name______
Address______
City______State_____ Zip______
Phone______Email______
Date of Application______
EDUCATION:
University Major Field Dates Attended Degree/Date
1.______
2.______
3.______
4.______
5.______
PROFESSIONAL EXPERIENCE
At least five years of postdoctoral experience as a psychologist? __Yes ___No
If Yes, from: ______to: ______
MEMBERSHIPS--check appropriate designation
American Psychological Association ___Fellow ___Member
American Society of Clinical Hypnosis ___Fellow ___Member
Society for Clinical and Experimental Hypnosis ___Fellow ___Member
ENTITLEMENTS
Photocopy of certificate or license: State______Number______
Diplomate of ABPP: Specialty______Year______
TRAINING IN HYPNOSIS
Course Name Course Date University/Organization Instructor
1. ______
2.______
3.______
4.______
FOR APPLICANTS IN CLINICAL HYPNOSIS
1. Five years of continuous practice of clinical hypnosis .___Yes __No
2. Supervision in the practice of clinical hypnosis: (supervisor and dates)
______
FOR APPLICANTS IN EXPERIMENTAL HYPNOSIS
1. Five years of continuous practice of experimental hypnosis .___Yes __No
2. Supervision in the practice of hypnosis research: (supervisor and dates)
______
FOR ALL APPLICANTS
Area or areas of specialization and theoretical orientation: ______
______
______
______
______
Give the names and addresses of three professionals who are familiar with your training and experience in the field of hypnosis in which you are applying for the diplomate.
Name:______
Address______
______
Name:______
Address______
______
______
Name:______
Address______
______
Please return this application with a curriculum vitae and a check in the amount of $100.00, made payable to our treasurer, Marc I. Oster, PsyD, ABPH.
Send the application and fee to one of the Secretaries below:
Akira Otani, Ed.D, ABPH
c/o Spectrum Behavioral Health
1509 Ritchie Highway, Suite F
Arnold, MD 21012
(410) 757-2077
Art Brambila, Ph.D., ABPH
c/o UNM-HSC's Children's Psychiatric Center
1001 Yale Blvd. NE,
Albuquerque, NM 87131
505-272-0371
fax: 505 272-0052
2007